Abstract
To the Editors,
The article titled ‘Becoming a patient-illness representations of depression of Anglo-Australian and Sri Lankan patients through the lens of Leventhal’s illness representational model’ was read by us with much interest (Antoniades, Mazza, & Brijnath, 2017). We believe this study is important in understanding the psychopathology among South-Asians living in the Western world.
After obtaining independence from Britain, Sri Lanka had experienced three decades of armed conflict in the North and a devastating Tsunami in 2004. Despite these atrocities, the country has managed to maintain high health standards in the region (World Health Organization (WHO), 2017). However, in regard to mental health, lack of mental health literacy and stigmatizing attitudes are found (Ediriweera, Fernando, & Pai, 2012). This leads to patients presenting late to services and experiencing a long duration of untreated psychosis (Chandradasa, Champika, Gunathillaka, & Mendis, 2016).
In Sri Lanka, Buddhists (70%) and Hindus (13%), comprising the majority, are believers of the Karma system, which is conceptualized as the actions driven by intentions and the belief that a deed done deliberately would lead to future consequences (Gombrich, 1997). Karma seems to be a culturally acceptable form of guilt (Abeyasinghe, Tennakoon, & Rajapakse, 2012) and Sri Lankans are found to be less likely to express guilt directly (Ball et al., 2010).
Beliefs on Karma provide a sense of meaning and control over the coping process (Phillips, Michelle Cheng, Oemig, Hietbrink, & Vonnegut, 2012). When recovering from medical illnesses, a patient may engage in positive thinking and cultural rituals to influence karma, suggesting an internal locus of control (Yamey & Greenwood, 2004). In contrast, another patient may attribute the causality of the illness to Karmic fate and feel helpless, suggesting an external locus of control (Phillips et al., 2012). As found in the study, Sri Lankans attribute difficulties arisen due to depression on to situational triggers (Antoniades et al., 2017), as perceived to be caused by past Karma. They would be hopeful that once the Karma is spent, their situation and health would improve. In Sri Lanka, patients would resort to spiritual healing methods before consulting a psychiatrist (Chandradasa & Kuruppuarachchi, 2017). A similar trend of reluctance to engage in pharmacotherapy was seen among the Sri Lankans in Australia (Antoniades et al., 2017).
A significant difference compared to motherland Sri Lankans was the lack of somatization. Studies in Sri Lanka show psychomotor symptoms were commonly reported by depressed patients (Ball et al., 2010). The perceived stigma related to psychiatric disorders may influence the less volunteering of psychological symptoms and express more somatic symptoms to the professionals (Ryder et al., 2008). A culturally valid tool focusing on somatization, such as the Peradeniya Depression Scale may have helped (Abeyasinghe et al., 2012). However, it is also possible that the somatization symptoms reduced over the course of the illness as the authors suggested or presentation of depression altered due to living in Australia. Overall, this study is remarkable in highlighting the transcultural factors and it would be interesting to conduct a similar study in Sri Lanka.
